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McFarland A, Reilly J, Manoukian S, Mason H. The economic benefits of surgical site infection prevention in adults: a systematic review. J Hosp Infect 2020; 106:76-101. [PMID: 32417433 DOI: 10.1016/j.jhin.2020.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/11/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) present a significant burden to healthcare and patients in terms of excess length of stay, distress, disability and death. SSI risk and the associated economic burden may be reduced through adherence to prevention guidelines although the irreducible minimum is unclear. AIM To evaluate the methods used to estimate the cost-effectiveness of prevention strategies for all SSIs. METHODS PubMed, Medline, CINAHL, and UK National Health Service Economic Evaluation Database were searched from inception to January 2020 to identify English language economic evaluation studies, embedded economic evaluations, and studies with some analysis in relation to cost and benefit in adult patients receiving surgical care in any setting. Risk of bias was assessed using two published checklists. FINDINGS Thirty-two studies involving 24,043 participants were included. Most studies evaluated SSI prevention in orthopaedic surgeries. Antibiotic prophylaxis, screening, treating, or decolonization of meticillin-resistant Staphylococcus aureus and surgical wound closure were the main methods evaluated. Methods ranged from cost-analyses to cost-effectiveness and cost-utility analyses. Synthesis of results was not possible due to heterogeneity. All studies reported some economic benefit associated with preventing SSI; however, measures of benefit were not reported consistently and the quality of studies was low to moderate. Limited evidence in relation to SSI impact on quality of life was identified. CONCLUSION Current evidence in relation to the economic benefits of SSI prevention is limited. Further robust studies that utilize sound economic and epidemiological methods are required to inform future investment decisions in SSI prevention.
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Affiliation(s)
- A McFarland
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.
| | - J Reilly
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - S Manoukian
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - H Mason
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
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Matza LS, Kim KJ, Yu H, Belden KA, Chen AF, Kurd M, Lee BY, Webb J. Health state utilities associated with post-surgical Staphylococcus aureus infections. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:819-827. [PMID: 30887157 PMCID: PMC6652168 DOI: 10.1007/s10198-019-01036-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 02/08/2019] [Indexed: 05/12/2023]
Abstract
INTRODUCTION Surgical site infections (SSIs) are among the most common and potentially serious complications after surgery. Staphylococcus aureus is a virulent pathogen frequently identified as a cause of SSI. As vaccines and other infection control measures are developed to reduce SSI risk, cost-utility analyses (CUA) of these interventions are needed to inform resource allocation decisions. A recent systematic review found that available SSI utilities are of "questionable quality." Therefore, the purpose of this study was to estimate the disutility (i.e., utility decrease) associated with SSIs. METHODS In time trade-off interviews, general population participants in the UK (London, Edinburgh) valued health states drafted based on literature and clinician interviews. Health states described either joint or spine surgery, with or without an SSI. The utility difference between otherwise identical health states with and without the SSI represented the disutility associated with the SSI. RESULTS A total of 201 participants completed interviews (50.2% female; mean age = 46.2 years). Mean (SD) utilities of health states describing joint and spine surgery without infections were 0.79 (0.23) and 0.78 (0.23). Disutilities of SSIs ranged from - 0.03 to - 0.32, depending on severity of the infection and subsequent medical interventions. All differences between corresponding health with and without SSIs were statistically significant (all p < 0.001). CONCLUSION The preference-based SSI disutilities derived in this study may be used to represent mild and serious SSIs in CUAs assessing and comparing the value of vaccinations that may reduce the risk of SSIs.
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Affiliation(s)
- Louis S. Matza
- Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, MD 20814 USA
| | - Katherine J. Kim
- Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, MD 20814 USA
| | - Holly Yu
- Pfizer Inc, Collegeville, PA USA
| | - Katherine A. Belden
- Sydney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA
| | - Antonia F. Chen
- Department of Orthopaedics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Mark Kurd
- Department of Orthopedic Surgery Sidney Kimmel Medical College, Thomas Jefferson University The Rothman Institute, Philadelphia, PA USA
| | - Bruce Y. Lee
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD USA
| | - Jason Webb
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
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Rennert-May E, Conly J, Smith S, Puloski S, Henderson E, Au F, Manns B. A cost-effectiveness analysis of mupirocin and chlorhexidine gluconate for Staphylococcus aureus decolonization prior to hip and knee arthroplasty in Alberta, Canada compared to standard of care. Antimicrob Resist Infect Control 2019; 8:113. [PMID: 31338160 PMCID: PMC6625116 DOI: 10.1186/s13756-019-0568-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 07/04/2019] [Indexed: 12/29/2022] Open
Abstract
Background While decolonization of Staphylococcus aureus reduces surgical site infection (SSI) rates following hip and knee arthroplasty, its cost-effectiveness is uncertain. We sought to examine the cost-effectiveness of a decolonization protocol for Staphylococcus aureus prior to hip and knee replacement in Alberta compared to standard care – no decolonization. Methods Decision analytic models and a probabilistic sensitivity analysis were used for a cost-effectiveness analysis, with the effectiveness of decolonization based on a large published pre- and post- intervention trial. The primary outcomes of the models were infections prevented and health care costs. We modelled the cost-effectiveness of decolonization in a hypothetical cohort of adult patients undergoing hip and knee replacement in Alberta, Canada. Information on the incidence of complex surgical site infections (SSIs), as well as the cost of care for patients with and without SSIs was taken from a provincial infection control database, and health administrative data. Results Use of the decolonization bundle was cost saving compared to usual care ($153/person), and resulted in 16 complex Staphylococcus aureus SSIs annually as opposed to 32 (with approximately 8000 hip or knee arthroplasties performed). The probabilistic sensitivity analysis demonstrated that the majority (84%) of the time the decolonization bundle was cost saving. The model was robust to one-way sensitivity analyses conducted within plausible ranges. There were small upfront costs associated with using a decolonization protocol, however, this model demonstrated cost savings over one year. In a Markov model that considered the impact of a decolonization bundle over a lifetime as it pertained to the need for subsequent joint replacements and patient quality of life, the bundle still resulted in cost savings ($161/person). Conclusions Decolonization for Staphylococcus aureus prior to hip and knee replacements resulted in cost savings and fewer SSIs, and should be considered prior to these procedures. Electronic supplementary material The online version of this article (10.1186/s13756-019-0568-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elissa Rennert-May
- 1Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - John Conly
- 2Departments of Medicine; Microbiology, Immunology and Infectious Diseases; Pathology and Laboratory Medicine, O'Brien Institute for Public Health; Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Canada
| | - Stephanie Smith
- 3Department of Medicine, University of Alberta, Edmonton, Canada
| | - Shannon Puloski
- 4Department of Surgery, University of Calgary, Calgary, Canada
| | - Elizabeth Henderson
- 5Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Flora Au
- 6Department of Medicine, University of Calgary, Calgary, Canada
| | - Braden Manns
- 7Departments of Medicine and Community Health Sciences, O'Brien Institute for Public Health and Libin Cardiovascular Institute, University of Calgary, HRIC Building, 2500 University Drive NW, Calgary, AB T2N1N4 Canada
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Abstract
INTRODUCTION Several studies have evaluated the efficacy of home use of chlorhexidine before surgery to reduce bacterial colonization. However, these studies have provided conflicting evidence about the potential efficacy of this strategy in decreasing bacterial loads and infection rates across surgical populations, and no prior study has analyzed the benefit of this intervention before spine surgery. We prospectively analyzed the effectiveness of chlorhexidine gluconate wipes for decreasing bacterial counts on the posterior neck. METHODS Sixteen healthy adults participated in this prospective study. The right side of each participant's neck was wiped twice (the night before and the morning of the experiment) with chlorhexidine gluconate wipes. The left side was used as the control region. Bacterial swabs were obtained as a baseline upon enrollment in the study, then upon arrival at the hospital, and, finally, after both sides of the neck had received standard preoperative scrubbing. RESULTS All patients had positive baseline bacterial growth (median >1,000 colonies/mL). When chlorhexidine gluconate wipes were used, decreased bacterial counts were noted before the preoperative scrub, but this finding was not statistically significant (P = 0.059). All patients had zero bacteria identified on either side of their neck after completion of the preoperative scrub. CONCLUSION At-home use of chlorhexidine gluconate wipes did not decrease the topical bacterial burden. Therefore, using chlorhexidine gluconate wipes at home before surgery may offer no added benefit.
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Lee BY, Mueller LE, Tilchin CG. A systems approach to vaccine decision making. Vaccine 2016; 35 Suppl 1:A36-A42. [PMID: 28017430 DOI: 10.1016/j.vaccine.2016.11.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 11/04/2016] [Accepted: 11/05/2016] [Indexed: 12/14/2022]
Abstract
Vaccines reside in a complex multiscale system that includes biological, clinical, behavioral, social, operational, environmental, and economical relationships. Not accounting for these systems when making decisions about vaccines can result in changes that have little effect rather than solutions, lead to unsustainable solutions, miss indirect (e.g., secondary, tertiary, and beyond) effects, cause unintended consequences, and lead to wasted time, effort, and resources. Mathematical and computational modeling can help better understand and address complex systems by representing all or most of the components, relationships, and processes. Such models can serve as "virtual laboratories" to examine how a system operates and test the effects of different changes within the system. Here are ten lessons learned from using computational models to bring more of a systems approach to vaccine decision making: (i) traditional single measure approaches may overlook opportunities; (ii) there is complex interplay among many vaccine, population, and disease characteristics; (iii) accounting for perspective can identify synergies; (iv) the distribution system should not be overlooked; (v) target population choice can have secondary and tertiary effects; (vi) potentially overlooked characteristics can be important; (vii) characteristics of one vaccine can affect other vaccines; (viii) the broader impact of vaccines is complex; (ix) vaccine administration extends beyond the provider level; and (x) the value of vaccines is dynamic.
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Affiliation(s)
- Bruce Y Lee
- Public Health Computational and Operations Research (PHICOR), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
| | - Leslie E Mueller
- Public Health Computational and Operations Research (PHICOR), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Carla G Tilchin
- Public Health Computational and Operations Research (PHICOR), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Gheorghe A, Moran G, Duffy H, Roberts T, Pinkney T, Calvert M. Health Utility Values Associated with Surgical Site Infection: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:1126-37. [PMID: 26686800 DOI: 10.1016/j.jval.2015.08.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 06/29/2015] [Accepted: 08/03/2015] [Indexed: 05/26/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is a costly postoperative complication whose impact on patients' health-related quality of life is highly uncertain and has not been summarized to date. OBJECTIVE The objective was to summarize the evidence base on SSI health utility values reported in patient-level studies and decision models. METHODS A systematic review of SSI utility values reported in patient-level and decision modeling studies was carried out. Studies in which utility values for SSI were either invoked (e.g., model-based economic evaluations) or elicited (e.g., valuation exercises), or at least one non-preference-based instrument was administered to patients with SSI after open surgery were included. Mapping algorithms were used, where appropriate, to calculate utilities from primary data. Results were summarized narratively, and the quality of the utility values used in the included modeling studies was assessed. RESULTS Of 6552 records identified in the database search, 28 studies were included in the review: 19 model-based economic evaluations and 9 patient-level studies. SSI utility decrements ranged from 0.04 to 0.48, of which 19 ranged from 0.1 to 0.3. SSI utility decrements could be calculated for three patient-level studies, and their values ranged from 0.05 (7 days postoperatively) to 0.124 (1 year postoperatively). In most modeling studies, SSI utilities were informed by authors' assumptions or by secondary sources. CONCLUSIONS SSI may substantially affect patients' health utility and needs to be considered when modeling decision problems in surgery. The evidence base for SSI utilities is of questionable quality and skewed toward orthopedic surgery. Further research must concentrate on producing reliable estimates for patients without orthopedic problems.
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Affiliation(s)
- Adrian Gheorghe
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
| | - Grace Moran
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Helen Duffy
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Tracy Roberts
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Thomas Pinkney
- Academic Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Melanie Calvert
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
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Kapadia BH, Johnson AJ, Issa K, Mont MA. Economic evaluation of chlorhexidine cloths on healthcare costs due to surgical site infections following total knee arthroplasty. J Arthroplasty 2013; 28:1061-5. [PMID: 23540539 DOI: 10.1016/j.arth.2013.02.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 02/08/2013] [Accepted: 02/20/2013] [Indexed: 02/01/2023] Open
Abstract
The purpose of this study was to evaluate the overall annual healthcare cost savings of adding a pre-operative chlorhexidine cloth preparation protocol. We used reports from the National Healthcare Safety Network and previously published reports to determine a range of surgical site infection rates following total knee arthroplasty and the cost per revision procedure. The savings listed are potential, but may be less. The cost benefit of using chlorhexidine at our institution per 1,000 total knee arthroplasty patients was a net savings of approximately $2.1 million. The annual healthcare savings ranged from $0.78 to $3.18 billion. This epidemiologic evaluation of using chlorhexidine prior to undergoing total knee arthroplasty has demonstrated the potential to decrease healthcare costs primarily by decreasing the incidence of surgical site infections.
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Affiliation(s)
- Bhaveen H Kapadia
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA
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The value of chlorhexidine gluconate wipes and prepacked washcloths to prevent the spread of pathogens--a systematic review. Aust Crit Care 2013; 26:158-66. [PMID: 23827390 DOI: 10.1016/j.aucc.2013.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/15/2013] [Accepted: 05/27/2013] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Use of chlorhexidine gluconate wipes and pre-packed washcloths has been described for preventing pathogen spread in healthcare settings. AIM To assess the impact of chlorhexidine washcloths/wipes in preventing the spread of pathogens. METHODS Extensive and structured literature search from studies in Google Academic, Cochrane Library, Web of Science, Pubmed and Cinahl from their inception until November 2012. FINDINGS Final analysis included 15 studies, 9 of which were randomised controlled trials. The most frequent setting was the intensive care unit. In intensive care units, a significant reduction of bloodstream infection was associated with intervention and 3 studies revealed a decrease in blood culture contamination. One study showed a decrease in staff and environmental contamination and no increase in chlorhexidine resistance with intervention. Positive blood cultures for multiple pathogens also declined with intervention. In a paediatric intensive care unit, intervention decreased bacteraemia and catheter-associated bloodstream infection. In hospital wards, intervention was associated to a 64% reduction of pathogen transmission. One study had no statistically significant results. Pre-surgical chlorhexidine use significantly decreased bacterial colonisation but had no impact on surgical site infections. Regarding maternal and perinatal setting, one study did not show reduction of early onset neonatal sepsis and pathogen transmission. Another study of vaginal and neonatal decolonisation with chlorhexidine wiping revealed significant reduction in colonisation. One study concluded that single and multiple umbilical cord cleansing reduced the likelihood for a positive swab in 25% and 29%, respectively. Neonatal wiping maintained low levels of skin colonisation for a 24h period, for multiple pathogens. CONCLUSION Current evidence supports the usefulness of chlorhexidine washcloths and wipes in an intensive care, hospital and pre-surgical setting. More studies are required to encourage its use for prevention of perinatal and neonatal transmission of pathogens.
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Boubekri A. Reducing Central Line-Associated Bloodstream Infections in the Blood and Marrow Transplantation Population: A Review of the Literature. Clin J Oncol Nurs 2013; 17:297-302. [DOI: 10.1188/13.cjon.297-302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
PURPOSE OF REVIEW Recent studies have assessed interventions and bundles of interventions to prevent surgical site infections (SSIs). We reviewed numerous studies to identify those with the strongest evidence supporting interventions for preventing SSIs. RECENT FINDINGS Bundles that included more than one intervention to decrease the risk of Staphylococcus aureus wound contamination, such as chlorhexidine bathing and nasal application of mupirocin, had the strongest supporting evidence. However, bundles should be tested to ensure that their components are not antagonistic. Vancomycin prophylaxis and extended antimicrobial prophylaxis should not be used routinely, but should be reserved for high-risk populations such as patients who carry methicillin-resistant S. aureus (MRSA). Novel interventions to prevent SSIs (e.g., topical or oral antimicrobial agents, skin sealant, and antimicrobial sutures) need further evaluation before surgeons implement them routinely. SUMMARY There is some evidence that bundled interventions can reduce SSIs. However, more research should be done evaluating the effectiveness of these interventions. Future studies of bundles should use robust methodologies, such as randomized controlled trials, cluster randomized trials, or quasi-experimental studies analyzed by time series analysis.
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Impact of non-rinse skin cleansing with chlorhexidine gluconate on prevention of healthcare-associated infections and colonization with multi-resistant organisms: a systematic review. J Hosp Infect 2012; 82:71-84. [DOI: 10.1016/j.jhin.2012.07.005] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 07/07/2012] [Indexed: 11/20/2022]
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Bailey RR, Stuckey DR, Norman BA, Duggan AP, Bacon KM, Connor DL, Lee I, Muder RR, Lee BY. Reply to Webster and Osborne. Infect Control Hosp Epidemiol 2011. [DOI: 10.1086/662024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Webster J, Osborne S. Home-based preoperative chlorhexidine bathing cloths to prevent surgical site infection. Infect Control Hosp Epidemiol 2011; 32:1047; author reply 1047-8. [PMID: 21931260 DOI: 10.1086/662020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Maya JJ, Ruiz SJ, Pacheco R, Valderrama SL, Villegas MV. Papel de la clorhexidina en la prevención de las infecciones asociadas a la atención en salud. INFECTIO 2011. [DOI: 10.1016/s0123-9392(11)70749-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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